Showing papers in "Texas Heart Institute Journal in 2001"

The Role of Interleukin-6 in Cases of Cardiac Myxoma: Clinical Features, Immunologic Abnormalities, and a Possible Role in Recurrence

Abstract: We performed this prospective study to evaluate the correlation of interleukin-6 serum levels with preoperative constitutional symptoms and immunologic abnormalities, and the possible role played by this cytokine in tumor recurrence. Eight patients with atrial myxoma were evaluated at our institution from July 1993 to November 1998. We measured their interleukin-6 serum levels by enzyme-linked immunosorbent assay method preoperatively and 1 and 6 months after surgery. Two of the cases involved recurrent tumor; 1 patient had undergone his 1st surgery at a different institution and died during the 2nd procedure, so his data were incomplete. Preoperatively, the whole group of patients had elevated interleukin-6 serum levels. Although patients with a 1st occurrence of tumor demonstrated a positive correlation between interleukin-6 serum level and tumor size, the 2 patients with recurrent tumors appeared to have higher interleukin-6 levels regardless of tumor size. Once the tumor was surgically removed, interleukin-6 levels returned to normal values, and this was associated with regression of clinical manifestations and immunologic features. According to our study, the overproduction of interleukin-6 by cardiac myxomas is responsible for the constitutional symptoms and immunologic abnormalities observed in patients with such tumors and might also play a role as a marker of recurrence. This study also suggests that recurrent cardiac myxomas form a subgroup of cardiac myxomas with a highly intrinsic aggressiveness, as implied by their greater interleukin-6 production despite their smaller size. Further studies are needed to confirm these results.

Mitral valve repair in a predominantly rheumatic population. Long-term results.

Abstract: Valve repair in rheumatic patients poses special problems due to valve deformity and mixed lesions. We present our experience from January 1988 through June 1999, in this retrospective study of 818 patients (377 males). The mean age was 22.8 +/- 11.3 years (range, 2 to 70 years). The cause of mitral regurgitation was rheumatic in 718 (88%) patients, congenital in 51, myxomatous in 34, infective in 7, and ischemic in 8. Most patients (64%) were in New York Heart Association functional class III or IV. Congestive heart failure was present in 116 patients (14%). Reparative procedures included posterior collar annuloplasty (n=710), commissurotomy (n=482), cusp-level chordal shortening (n=237), cusp thinning (n=222), cleft suture (n= 166), and cusp excision/plication (n=42). Operative mortality was 4% (32 patients). Preoperative left ventricular dysfunction, presence of congestive heart failure, and advanced functional class were associated with greater mortality. Follow-up ranged from 1 to 144 months (mean, 44.9 +/- 33.2 months) and was 96% complete. Most survivors (70%) had no or trivial mitral regurgitation. Forty patients required reoperation for valve dysfunction. There were 23 (2.8%) late deaths. Actuarial, reoperation-free, and event-free survival at 11 years were 92.6% +/- 1.0%, 65.0% +/- 10%, and 38% +/- 6.0%, respectively Among the survivors, 85% were in New York Heart Association functional class I. We conclude that mitral valve repair in rheumatic patients, using current techniques, can effectively correct hemodynamic and functional abnormalities with satisfactory results.

Gender and cardiac arrhythmias.

Abstract: The incidence of certain clinical arrhythmias varies between and women. Clinical and experimental observations suggest the existence of true differences in electrophysiologic properties between the sexes. We review these differences, possible mechanisms, clinical implications, and therapeutic considerations in the treatment of various arrhythmias in women. (Tex Heart Inst J 2001;28:265–75)

Coronary artery fistula. Management and intermediate-term outcome after transcatheter coil occlusion.

Abstract: During the last 2 decades, transcatheter occlusion of coronary artery fistulae has developed into a safe and effective therapy for children. This procedure avoids the need for open surgical repair and the attendant complications of cardiopulmonary bypass and median sternotomy. The long-term outcome in patients after transcatheter occlusion remains unknown. We describe the intermediate-term progress of 4 such patients after coil occlusion of coronary artery fistulae. Persistent coronary artery dilatation was present in all patients reviewed, as late as 4 years after occlusion.

Charles Theodore Dotter: The Father of Intervention

Abstract: The 1st percutaneous transluminal angioplasty marked a new era in the treatment of peripheral atherosclerotic lesions. The early techniques used in peripheral percutaneous transluminal angioplasty form the basis for subsequent percutaneous intervention both in the peripheral and coronary arteries and are largely the contribution of Charles Dotter. Dotter was the 1st to describe flow-directed balloon catheterization, the double-lumen balloon catheter, the safety guidewire, percutaneous arterial stenting, and more. This practical genius dedicated his considerable energy to the belief that there is always a better way to treat disease. His personal contributions to clinical medicine, research, and teaching have saved millions of limbs and lives all over the world.

Asymptomatic giant right atrial aneurysm.

Abstract: A 5-year-old asymptomatic boy was found incidentally, on a chest radiograph, to have gross cardiomegaly; further evaluation by echocardiography showed a giant right atrial aneurysm. The patient underwent successful surgical reduction of the right atrium, closure of an atrial septal defect, and tricuspid valve repair. These measures were taken to prevent thrombus formation in the right atrium, prevent paradoxical embolism, and lower the risk of atrial arrhythmias. The morphologic features of the resected atrial tissue showed paper-thin wall with a central aneurysm and focal endocardial fibrosis consistent with a diagnosis of idiopathic dilatation of the right atrium. (Tex Heart Inst J 2001; 28:301–3)

Aneurysm of the Left Atrial Appendage

Abstract: A 43-year-old woman underwent excision of an aneurysm of the left atrial appendage, which had been causing cerebrovascular embolic episodes. We attribute the aneurysm to congenital dysplasia of the musculi pectinati in the left atrial appendage and of the bands of atrial muscle from which they arise. In Appendix I, we draw attention to the morphologically similar arrangements of inner and outer bands that emanate from a common transverse interatrial band and yield morphologically similar medial, descending, and ascending palm-leaf arrangements of musculi pectinati. In addition, we observe that the strap-like arrangements of musculi in both atria connect the outer band with the para-annular segment of the inner band. In Appendix II, we briefly review the literature concerning musculi pectinati and related bands.

Supernormal Left Ventricular Diastolic Function in Triathletes

Abstract: We studied the structural and functional heart adaptations of 52 male triathletes compared with those of 22 active, nonathletic men, by 2-dimensional Doppler echocardiography. Left ventricular diastolic function was evaluated by recording transmitral flow velocities. To exclude the influences of preload, left atrial pressure, and aortic pressure, left ventricular diastolic function was also evaluated by pulsed Doppler tissue imaging. Significant differences in cardiac structure and function were observed between the 2 groups. In the triathletes, the left ventricular diastolic function was completely normal, despite signs of mixed eccentric and concentric left ventricular hypertrophy, and this function was better than that in the control group. We measured 2 aspects of the late passive diastolic filling period in the triathletes: ASEAC value (the amplitude of excursion of the interventricular septal endocardium at the end of left ventricular diastole just after atrial contraction); and the time between onset of the P wave on the electrocardiographic tracing and onset of systolic septal movement on M-mode echocardiography. Pulsed Doppler tissue imaging confirmed these results. The E/A ratios (peak early left ventricular diastolic motion velocity divided by the peak atrial systolic motion velocity), measured by pulsed Doppler tissue imaging, yielded even more evidence for supernormal left ventricular diastolic function in the triathletes. Left ventricular relaxation and filling properties were measured along the longitudinal and transverse axes by pulsed Doppler tissue imaging, which was useful for evaluating left ventricular diastolic function. We determined that triathletes may develop supernormal left ventricular diastolic function with increased diastolic reserves.

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms.

Abstract: Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms can be complicated by renal, hepatic, and intestinal ischemia. To determine whether suprarenal or supraceliac clamping increases morbidity and mortality we retrospectively reviewed our recent nonrandomized experience. Between January 1993 and December 1998, 716 patients underwent elective (n=682) or urgent (n=34) infrarenal abdominal aortic aneurysm repair. Infrarenal clamping was used in 516 (72. 1 %) and suprarenal or supraceliac clamping in 200 (279%). The suprarenal/supraceliac group had significantly more older patients (> or = 70 years of age) (65.5% vs 477%) and a higher incidence of preoperative renal insufficiency (75% vs 5.5%). Suprarenal or supraceliac clamping was used during repair of ruptured (n=25), juxtarenal (n=7), or inflammatory abdominal aortic aneurysms (n=4); during concomitant renal or visceral revascularization (n=43); in other difficult settings (n=13); or at the surgeon's discretion (n=108). The decision for such clamping was always made during surgery In treating ruptured aneurysms, suprarenal/supraceliac clamping (25/200) was used more often than infrarenal clamping (9/516) (12.5% vs 1.74%). Operative times were similar in both groups, but transfusion requirements and length of hospital stay were slightly greater in the suprarenal/supraceliac group. Perioperative mortality was 3.1% overall, but higher in the suprarenal/ supraceliac group than in the infrarenal (75% vs 1.4%). Postoperative complications developed in 26 (13%) of patients who underwent suprarenal/supraceliac clamping. Abdominal re-exploration was required in 9 other patients. We conclude that, despite associated comorbidities, elective suprarenal/supraceliac clamping during infrarenal abdominal aortic aneurysm repair is safe, facilitates repair, and does not significantly increase mortality.

Neurologic complications after deep hypothermic circulatory arrest: types, predictors, and timing.

Abstract: To determine the nature of neurologic dysfunction after deep hypothermic circulatory arrest during aortic arch surgery, we reconsidered the cases of 154 patients who had undergone aortic arch surgery (either of the ascending or transverse aorta, or both) between November 1993 and July 1999. Temporary postoperative neurologic dysfunction was seen in 9 patients (5.8%), and another 3 patients (1.9%) experienced stroke. Patients with temporary neurologic dysfunction had no new infarct and were discharged home with no residual symptoms. Computed tomographic scans revealed that 2 patients with stroke had multiple infarcts in the brainstem, and the 3rd had bilateral border-zone infarcts. The patients with brainstem infarcts died on postoperative days 7 and 15, and the patient with border-zone infarct was discharged home with no symptoms 3 months after surgery. Univariate analysis revealed that patients with neurologic deficits had significantly higher rates of history of hypertension, concomitant coronary artery bypass grafting, cardiac ischemia times longer than 90 minutes, and chronic renal failure. A multivariate logistic regression analysis revealed that the significant preoperative variables associated with neurologic deficits were a history of hypertension and a cardiac ischemia time longer than 90 minutes. Deep hypothermic circulatory arrest is a safe and useful technique for protection of the brain during surgery for complex aortic problems. In future, some patients at extreme risk for perioperative neurologic complications might be offered novel neuroprotective agents, in combination with deep hypothermia.

Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics

Abstract: Blood Pressure Monitoring in Cardiovascular Medi-cine and Therapeutics is one in a series of texts titled Contemporary Cardiology. The focus of the present volume is on the circadian fluctuations of the cardiovascular system. It is intended for a readership of cardiologists, internists, endocrinologists, and nephrologists, as well as nurse practitioners, physician assistants, and others involved in the care of the hypertensive patient. The book is divided into 3 major sections. The 1st reviews techniques for out-of-office blood-pressure monitoring. The limitations of blood-pressure evaluation in the physician's office are examined, and various types of home blood-pressure monitors are discussed. The importance of interpreting data within the context of behavioral and environmental factors is underscored as the essential distinction between disease and adaptive physiologic response. Dr. White critically reviews the advantages and limitations of ambulatory monitoring, together with the economic issues surrounding it. The 2nd section of the book is its most scientific: it examines the circadian variations of the cardiovascular system. The major neurohormonal systems responsible for rhythmic hemodynamic oscillations are reviewed, and their relationship to the circadian variability of myocardial infarction, sudden cardiac death, and stroke is discussed. An entire chapter in this section is devot-ed to the evaluation of heart rate as an independent predictor of cardiovascular morbidity and mortality. Another focuses on the close interaction between the sympathetic and renin-angiotensin-aldosterone systems and the effects of these systems upon circadian variation. Finally, the 3rd section reviews important practical considerations regarding antihypertensive therapy, including the dependence of drug kinetics and dosing intervals upon the circadian variability of the cardiovascular system. The book concludes with a chapter that focuses on current and future use of ambulatory blood-pressure monitoring both in clinical practice and investigation. Notwithstanding some redundancy, this book provides an excellent, comprehensive analysis of circadian variability in the hypertensive patient. It also highlights the mounting evidence in favor of ambulatory monitoring and self-monitoring of blood pressure to more accurately discern blood-pressure trends. Hyper-tension remains a ubiquitous disease with independent risk for cardiovascular morbidity and mortality, despite decades of research and advances in pharmacology. Therefore, strategies to identify suboptimally controlled or widely variable blood pressure have a potential for great impact. This publication provides a practical framework for understanding hemodynamic variability and underscores the role of out-of-office blood-pressure monitoring in tailoring therapy to achieve 24-hour control.

Mitral valve replacement and repair. Report of 5 patients with systemic lupus erythematosus.

Abstract: Severe mitral valve regurgitation due to systemic lupus erythematosus is a rare cause of valvular heart disease, necessitating valve surgery. Currently, there are 36 case reports in the world medical literature of mitral valve replacement or repair in patients who have lupus. The current trend in mitral valve surgery is toward anatomic valve repair. In patients who have systemic lupus erythematosus, however, valve repair often leads to repeat surgery and valve replacement. We report the cases of 5 patients with lupus and severe mitral valve regurgitation who underwent mitral valve surgery. In 3 of these patients, replacement with a mechanical prosthetic mitral valve was performed with good long-term results. In the other 2 patients, mitral valve repair was performed, but only 1 of the repairs was successful. The 2nd patient required subsequent replacement with a mechanical valve. To our knowledge, this report of 5 patients is the largest series of mitral valve surgery in patients with lupus. These results, along with a review of the literature, suggest the superiority of mechanical prosthetic valve replacement to repair in patients who have systemic lupus erythematosus.

Iatrogenic Injury to the Long Thoracic Nerve: An Underestimated Cause of Morbidity after Cardiac Surgery

Abstract: After heart surgery, complications affecting the brachial plexus have been reported in 2% to 38% of cases. The long thoracic nerve is vulnerable to damage at various levels, due to its long and superficial course. This nerve supplies the serratus anterior muscle, which has an important role in the abduction and elevation of the superior limb; paralysis of the serratus anterior causes "winged scapula," a condition in which the arm cannot be lifted higher than 90 degrees from the side. Unfortunately the long thoracic nerve can be damaged by a wide variety of traumatic and nontraumatic occurrences, ranging from viral or nonviral disease to improper surgical technique, to the position of the patient during transfer to a hospital bed. Our patient, a 62-year-old man with triple-vessel disease, underwent myocardial revascularization in which right and left internal thoracic arteries and the left radial artery were grafted to the right coronary, descending anterior, and obtuse marginal arteries, respectively. Despite strong recovery and an apparently good postoperative course, the patient sued for damages due to subsequent winging of the left scapula. In this instance, the legal case has less to do with the cause of the lesion (which remains unclear) than with failure to adequately inform the patient of possible complications at the expense of the nervous system. The lesson is that each patient must receive detailed written and oral explanation of the potential benefits and all conceivable risks of a procedure.

Noninvasive Electrocardiology in Clinical Practice

Abstract: Interpreting Electrocardiograms Using Basic Principles and Vector Concepts is the latest addition to a series on fundamental and clinical cardiology, edited by Samuel Z. Goldhaber. The book reflects work done by Dr. Hurst during a lifetime of devotion to patient care, teaching, and writing about cardiovascular disease, including electrocardiographic interpretation. His interest in vector electrocardiography developed early in his career, during his relationship with Drs. Robert Grant and Harvey Estes in the department of cardiology at Emory University. This book explains the concepts that were originally described and popularized by Grant and Estes in Spatial Vector Electrocardiography in 1951. The volume is divided into 8 parts. Hurst's Part I, “How People Learn,” describes what he believes to be the key components of the learning process. Part II, “Historical Benchmarks and the Naming of the Waves,” is a tribute to the men who developed the basics of electrocardiographic tracings. Hurst has always emphasized the importance of the historical aspects of cardiology. The 3rd part describes the basic principles of electrocardiography. It is divided into 8 chapters that contain information essential to electrocardiographic interpretation. The 2 introductory chapters of this part describe the use of vectors to represent cardiac electrical forces and the electrical activity of myocytes. The next 4 chapters deal with the body as a conductor for the electrical activity of the heart, the anatomy of the heart chambers and conduction system, the process of depolarization and repolarization, and the electrocardiographic leads (including the contributions of Einthoven, Bayley, Goldberger, and Wilson). Part III ends with a chapter on how to measure cardiac electrical forces. Parts IV and V are brief discussions (a chapter each) about the use of the electrocardiogram as a diagnostic tool and the normal measurements of the different waves and intervals. Part V includes charts and figures of normal recordings. These figures display the correlation between QRS and T wave spatial vector directions in the frontal plane and their antero-posterior orientation. Part VI, the largest in the book, describes the most common electrocardiographic abnormalities and shows the vector relationships and their correlations with tracings. These chapters include the following topics: ventricular hypertrophy, myocardial infarction, abnormalities of the conduction system, pericarditis, pulmonary embolism, chronic obstructive lung disease, digitalis effects, and electrolyte disturbances. At the end of the book, Hurst briefly mentions other electrocardiographic abnormalities, which include preexcitation, postexcitation, the Brugada syndrome, and the long QT syndrome. A couple of drawbacks deserve mention. Some of the important figures are difficult to read and interpret because too much information is crammed into the space allowed. Additionally, the book costs $165, which puts it out of reach for many medical students and residents. Nevertheless, it is well written and informative and will be useful to students of medicine at all levels who wish to understand electrocardiography using vector concepts.

Tricuspid repair for infective endocarditis: clinical and echocardiographic results.

Abstract: We report our retrospective experience in the treatment of infective tricuspid endocarditis with valve repair From January 1981 through January 1999, 238 cases of infective endocarditis were seen at our institution, with tricuspid involvement in 19 cases. Tricuspid valve repair was performed in 9 patients whose valves had infective lesions involving a single leaflet. One goal of the repair was to avoid implanting any prosthetic material. At surgery, the posterior leaflet was completely excised and annuloplasty was performed in 4 patients. Wide quadrangular resection of the anterior leaflet and De Vega annuloplasty were performed in the other 5 patients. All patients had a good postoperative recovery Postoperative echocardiography showed no tricuspid regurgitation in 4 patients, mild regurgitation in 3, and moderate in 2. Follow-up ranged from 21 to 155 months (mean, 4756 +/- 50 [SD] months). Two late deaths occurred: one, 2 months postoperatively (sudden death), and the other, 108 months postoperatively (lung carcinoma). Late postoperative echocardiography showed no tricuspid regurgitation in 4 patients, mild in 2, and moderate in 2. No recurrent infection was observed. Tricuspid valve repair rather than valvulectomy or replacement is indicated in cases of right-sided endocarditis with single-leaflet involvement. Tricuspid repair enables eradication of the infection without implantation of prosthetic material.

The pitfalls of transthoracic echocardiography. A case of eustachian valve endocarditis.

Abstract: A case of infective endocarditis involving the vestigial eustachian valve is presented and the available English medical literature is reviewed. Only 5 prior cases have been reported: 4 of those required transesophageal echocardiography for diagnosis, and the other was found at autopsy. This clinical entity is routinely missed on transthoracic echocardiography. Injection drug use is a common predisposing factor, and Staphylococcus aureus is the most commonly identified organism. This report broadens the differential diagnosis of endovascular infections in injection drug users and highlights the importance of transesophageal echocardiography for diagnosis in selected patients.

Severe Rhabdomyolysis Associated with the Cerivastatin-Gemfibrozil Combination Therapy: Report of a Case

Abstract: Cerivastatin is the new 3rd-generation of the synthetic 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, the 1st drugs of choice for treating hypercholesterolemia. A potent inhibitor of HMG-CoA reductase, it possesses a high affinity for liver tissue and decreases plasma low-density lipoprotein cholesterol at microgram doses. Cerivastatin produces reductions in low-density lipoprotein cholesterol of 31.3% and 36.1% at doses of 0.3 and 0.4 mg/day, respectively. It is an uncomplicated agent with regard to its pharmacokinetic profile, low potential for interaction with other drugs, and suitability for use in those with impaired renal function. Most other statins have been implicated in causing rhabdomyolysis, either as mono-therapy or in combination with other agents. We report what to our knowledge is the most profound case yet in the literature of rhabdomyolysis in association with ceriva-statin-gemfibrozil combination therapy, in regard both to the extreme elevation in serum creatinine kinase and to the patient's near-paralytic weakness.

Right atrial myxoma in a patient presenting with syncope.

Abstract: A 77-year-old man with no notable medical history presented with syncope This was his 1st episode, and it had occurred while he was walking at his usual pace The physical examination revealed nothing unusual Electrocardiography showed normal sinus rhythm with nonspecific ST-T changes Transthoracic and transesophageal echocardiography revealed normal left ventricular size and function, but there was a 45- × 485-cm right atrial mass that was prolapsing through the tricuspid valve into the right ventricle during diastole (Figs 1 and 2) Surgical exploration of the right atrium revealed a 4- × 5-cm shiny mass attached to the interatrial septum The mass was successfully excised In addition, the patient underwent triple-vessel coronary artery bypass grafting Histologic examination of the mass confirmed the diagnosis of cardiac myxoma The patient recovered without complication Fig 1 Transthoracic echocardiography (apical 4-chamber view) showing the right atrial mass attached to the interatrial septum Fig 2 Transthoracic echocardiography (apical 4-chamber view) showing the right atrial mass prolapsing into the right ventricle Myxomas are the most common primary tumors of the heart Only about 15% to 20% of cardiac myxomas are located in the right atrium; most of these are attached to the interatrial septum 1 Right atrial myxomas can be asymptomatic In other cases, symptoms may arise from distal embolization, both pulmonary and systemic (paradoxical embolization through a patent foramen ovale) Myxomas may also manifest with a variety of constitutional signs and symptoms, including fever, weight loss, and arthralgias 2 In addition, the local tricuspid valvular obstruction resulting from a myxoma may mimic tricuspid stenosis Syncope, which occurred in this patient, is a rare manifestation of right atrial myxoma However, sufficiently large tumors can cause a temporary complete obstruction of the tricuspid valve, resulting in syncope or sudden death The best treatment is surgical removal of the mass, which is generally curative

Transapical Aortic Cannulation for Acute Aortic Dissection to Prevent Malperfusion and Cerebral Complications

Abstract: We describe a technique for transapical cannulation in cases of acute aortic dissection. This method entails aortic cannulation via the apex of the left ventricle and the aortic valve. When this technique is used, retrograde perfusion prevents such fatal complications as malperfusion or cerebral embolism that can occur with femoral cannulation. Having found no disadvantage in this method, we recommend transapical cannulation as the best cannulation technique for acute aortic dissection.

Giant left atrium.

Abstract: A 65-year-old man with a history of rheumatic heart disease and severe mitral stenosis and regurgitation underwent mitral valve replacement with a 27-mm St. Jude mechanical prosthesis (St. Jude Medical, Inc.; St. Paul, Minn). Chest radiography revealed marked prominence of the right cardiac border, a finding consistent with left atrial dilatation (Fig. 1). Two-dimensional echocardiography displayed massive left atrial enlargement (Figs. 2 and 3) with dimensions of 10.4 × 12.8 cm. The remaining chamber sizes, prosthetic mitral valve function, and left ventricular systolic function were normal. Fig. 1 Chest radiograph in the anteroposterior view revealing marked prominence of the right cardiac border (arrowheads) consistent with left atrial enlargement. Fig. 2 Transthoracic echocardiogram (parasternal short-axis view) of the left atrium (LA). Fig. 3 Transthoracic echocardiogram (apical 4-chamber view), showing the disproportionate size of the left atrium (LA) compared with the left ventricle (LV) and the other cardiac chambers. Left atrial enlargement is seen in a variety of cardiac conditions, including mitral valve disease, left ventricular failure, chronic atrial fibrillation, and left-to-right shunts such as those occurring with patent ductus arteriosus and ventricular septal defects. Giant left atria are defined as those measuring larger than 8 cm and are typically found in patients who have rheumatic mitral valve disease with severe regurgitation.

Cutaneous T-cell lymphoma in a cardiac transplant recipient.

Abstract: Mycosis fungoides, an uncommon form of cutaneous T-cell lymphoma, arises in the skin and frequently progresses to generalized lymphadenopathy Although the cause of cutaneous T-cell lymphoma is unknown, chronic immunosuppression may play a role. A few cases have been reported in renal transplant recipients; however, ours appears to be the 1st report of cutaneous T-cell lymphoma in a cardiac transplant recipient. In our patient, cutaneous manifestations of the disease were noted less than 1 year after transplantation. Seven years after transplantation, Sezary syndrome, a variant form of mycosis fungoides, was diagnosed by tissue biopsy and flow cytometry analysis. Photopheresis improved symptoms but was not well tolerated because of hemodynamic sequelae. Psoralen and ultraviolet A therapy also improved the patient's skin condition, but a generalized lymphadenopathy developed. The maintenance immunosuppressive regimen was changed from cyclosporine (3 mg/kg/day) and azathioprine to cyclosporine (1.5 mg/kg/day) and cyclophosphamide. Although effective in the short-term, the results of this therapeutic strategy could not be fully evaluated because the patient died of acute myocardial infarction.

Pseudo-false-positive exercise treadmill testing caused by systolic anterior motion of the anterior mitral valve leaflet

Abstract: Subendocardial ischemia as indicated by electrocardiography during exercise, in association with severe systolic anterior motion of the anterior mitral valve leaflet without left ventricular hypertrophy, has not been well described. We report the case of a 42-year-old man who presented with symptoms of exertional angina and 2-mm ST depression on treadmill electrocardiography but had a normal perfusion scan and coronary angiogram. Initially, the negative angiographic results caused us to regard the treadmill results as false-positive. Subsequently, low-dose dobutamine echocardiography showed severe systolic anterior motion of the anterior mitral valve leaflet with a >144-mmHg left ventricular outflow tract gradient; we then recognized the original treadmill results to be pseudo-false-positive. Electrocardiographic changes in association with the above-described motion of the anterior mitral valve leaflet and increased left ventricular outflow tract gradient were verified by use of treadmill and supine bicycle stress echocardiography. (Tex Heart Inst J 2001;28:308–11)

Regional Lidocaine Infusion Reduces Postischemic Spinal Cord Injury in Rabbits

Abstract: Paraplegia secondary to spinal cord ischemia is a devastating complication in operations on the descending and thoracoabdominal aorta. We hypothesized that the tolerance of the spinal cord to an ischemic insult could be improved by means of regional administration of lidocaine. Thirty-one New Zealand white rabbits were anesthetized and spinal cord ischemia was induced by the placement of clamps both below the left renal vein and above the aortic bifurcation. The animals were divided into 5 groups. Aortic occlusion time was 20 minutes in Group 1 and 30 minutes in all other groups. Groups 1 and 2 functioned as controls. Lidocaine (Group 5) or normal saline solution (Group 3) was infused into the isolated aortic segment after cross-clamping. Group 4 animals received 20% mannitol regionally, before and after reperfusion. Postoperatively, rabbits were classified as either neurologically normal or injured (paralyzed or paretic). Among controls, 20 minutes of aortic occlusion did not produce any neurologic deficit (Group 1: 0/4 injured), while 30 minutes of occlusion resulted in more consistent injury (Group 2: 6/8 injured). Animals that received normal saline (Group 3) or mannitol (Group 4) regionally showed 80% neurologic injury (4/5). Animals treated with the regional lidocaine infusion (Group 5) showed much better neurologic outcomes (7/9 normal: 78%). This superiority of Group 5 over Groups 2, 3, and 4 was significant (P < 0.02). We conclude that regional administration of lidocaine reduced neurologic injury secondary to spinal cord ischemia and reperfusion after aortic occlusion in the rabbit model.

Mitral valve regurgitation causing right upper lobe pulmonary edema.

Abstract: When radiography is performed in patients with mitral regurgitation, cardiogenic pulmonary edema is a typical finding; however, asymmetric pulmonary edema has also been reported. We describe the case of a patient in whom mitral valve regurgitation caused isolated pulmonary edema in the right upper lung. We include a discussion of pulmonary edema in conjunction with mitral regurgitation.

Right pulmonary artery-to-left atrium communication: a rare cause of systemic cyanosis.

Abstract: Direct communication between the right pulmonary artery and the left atrium is a rare congenital vascular malformation. The clinical diagnosis is difficult, and preoperative angiography is essential. We treated this anomaly successfully with surgery and the use of cardiopulmonary bypass in an 11-year-old boy. Surgery provides a complete cure for this anomaly.

Impact of double internal thoracic artery grafts on long-term outcomes in coronary artery bypass grafting.

Abstract: We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983-1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n= 139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n= 173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications.

Pulmonary Embolism after Pacemaker Implantation

Abstract: One day after implantation of a permanent pacemaker in an 82-year-old man, transthoracic echocardiography showed a mass in the right ventricle and a small pericardial effusion. Transesophageal echocardiography revealed a mass attached to the pacemaker lead. Subcutaneous administration of enoxaparin was begun, and the patient remained free of symptoms for the duration of his hospital stay. Follow-up echocardiography performed before discharge failed to show the right ventricular mass, but a lung perfusion scan revealed multiple bilateral perfusion defects consistent with pulmonary emboli. The patient was discharged on a regimen of enoxaparin for another 30 days. Two years later, he remained asymptomatic. (Tex Heart Inst J 2001;28:318–9)

Esophageal Perforation in a Sword Swallower

Abstract: This case report presents an unusual mechanism for a potentially lethal injury. Our search of the English-language medical literature revealed no other report of esophageal perforation resulting from sword swallowing. Management of such an injury is often difficult, and a favorable outcome is dependent on prompt diagnosis and treatment.

Sizing of Atrial Septal Defects to Predict Successful Closure with Transcatheter CardioSEAL™ Device

Abstract: We conducted this retrospective study to compare methods for measuring atrial septal defects and to identify factors affecting echocardiographic measurement of such defects before transcatheter closure with the CardioSEAL™ Septal Occluder. We reviewed the records of patients considered for device placement at our institution from January 1997 to April 1999. Atrial septal defect size was measured by transthoracic and transesophageal echocardiography; the stretched diameter was measured during catheterization by fluoroscopy and transesophageal echocardiography. The stretched-diameter fluoroscopic measurement was used for device size selection. Analysis of variance was used to calculate the effect of size, age, and size-by-age interaction. Thirty-one patients (3.3 to 72 years of age) underwent transthoracic and transesophageal echocardiography. One patient was excluded from catheterization because of a 25-mm septal defect as indicated by transesophageal echocardiography (our maximum diameter, 15 mm). Thirty patients underwent transcatheter stretched-diameter sizing; 5 were excluded from device implantation because of defects >20 mm by stretched-diameter fluoroscopy (4) or septal length insufficient for device support (1). Implantation was successful in 23/25 patients; 2/23 had a residual shunt. In patients with available results (26/30), the stretched diameter was the same whether measured by stretched-diameter fluoroscopy or transesophageal echocardiography (P=0.007, R square=0.963). Compared with stretched-diameter fluoroscopy, precatheterization transthoracic and transesophageal echocardiography underestimated defect size by a mean of 22% and 13.2%, respectively. When data from those same tests were compared in defects of ≤10 mm and >10 mm, transthoracic and transesophageal echo-cardiography were reliable predictors (P=0.003 and P=0.05, respectively) of stretched-diameter size in defects ≤10 mm.

Acute aortic valve regurgitation secondary to blunt chest trauma.

Abstract: Blunt injury to the cardiac valves leads to progressive acute ventricular failure, which often requires urgent surgical management. In this case report, we describe an acute aortic valve rupture caused by air-bag inflation during an automobile accident. Laceration of an aortic valve cusp was treated successfully with urgent aortic valve replacement. A concomitant orthopedic injury was treated electively 15 days after cardiac surgery. Acute aortic valve rupture is a very rare complication of blunt chest trauma. We discuss how to diagnose and manage this potentially catastrophic event. (Tex Heart Inst J 2001;28:312–4)